Comparing staging systems for predicting prognosis and survival in patients with hepatocellular carcinoma in Egypt

Abstract

Introduction: Several hepatocellular carcinoma (HCC) staging systems are available. Although the European Association for Study of Liver Diseases (EASL) and American Association for the Study of Liver Diseases (AASLD) recommended the use of Barcelona Clinic Liver Cancer (BCLC), many studies in different populations revealed heterogeneous results. The aim of this study was to compare different staging systems for predicting prognosis and survival, and for stratifying HCC patients for treatment at a national referral centre for liver disease in Egypt.

Methods: 2000 Patients were included in this study. Baseline demographic, clinical, laboratory, and radiological data were determined at diagnosis. Patients were stratified using the Okuda, BCLC, Cancer of the Liver Italian Program (CLIP), and Japan Integrated Staging (JIS). Patients' survival in different stages within each staging system and the validity of the system in predicting survival were compared.

Results: The overall survival was 15 months. The 1-, 2-, 3- and 4-year survival of the entire cohort was 56%, 34%, 25% and 15% respectively. The presence of ascites, multiple focal lesions, large tumour size >5 cm, portal vein thrombosis, extra-hepatic spread, AFP≥200 ng/ml and poor Child score were independent predictors of survival (p<0.001). All staging systems were significant in determining overall survival in univariate and multivariate analyses. BCLC was the most predictive staging system for the whole cohort (p<0.001). Among the subgroup of patients offered potentially curative therapy, BCLC was the most informative system in predicting patient survival (p<0.001). For patients with advanced HCC not amenable for specific therapy, CLIP was the best staging system for predicting prognosis (p<0.001).

Conclusion: BCLC staging system provided the best prognostic stratification for HCC patients. However, CLIP score has the highest stratification ability in patients with advanced HCC highlighting the importance of including AFP in best staging system.

Figure 1. Survival curves for whole cohort.

Kaplan-Meier survival curves for patients with hepatocellular carcinoma by staging system: (A) Okuda, (B) Barcelona Clinic Liver Cancer, (C) Cancer of the Liver Italian Program, (D) Japan Integrated Staging score.

Figure 2. Receiver operating characteristic (ROC) curve for whole cohort.

Discriminatory ability for death at one, two, and three years, evaluated by receiver operating characteristic (ROC) curve area, for Okuda, CLIP, BCLC and JIS scores for whole cohort.

Figure 3. Survival curves for patients not amenable to treatment.

Probability of survival for patients not amenable to treatment according to (A) CLIP score, (B) BCLC staging system.

Figure 4. ROC curve for patients not amenable to treatment.

Discriminatory ability for death at one, two, and three years, evaluated by receiver operating characteristic (ROC) curve area, for CLIP and BCLC staging system for patients not amenable to treatment.